Long-duration upper extremity surgery under brachial plexus block combined with intravenous dexmedetomidine sedation without an anesthesiologist.

BACKGROUND: Dexmedetomidine (DEX) provides a unique conscious sedation without respiratory depression. We examined the usefulness of intravenous (IV) DEX sedation combined with brachial plexus block for long-duration upper extremity surgery without an anesthesiologist. METHODS: We retrospectively reviewed 90 limbs of 86 patients and measured the actual operative time course in detail. The adverse events and the patient-reported outcomes regarding intraoperative pain and depth of sedation were evaluated. RESULTS: The mean total time of the operation, tourniquet use, and the IV DEX sedation were 150 min, 132 min, and 117 min, respectively. The mean time between discontinuation of IV DEX sedation and completion of the operation was 51 min. The intraoperative adverse events involved bradycardia (21%), hypotension (18%), and oxygen desaturation (3%). The mean visual analog scale scores of pain during brachial plexus block, surgical site pain, tourniquet pain, and depth of the sedation were 23.4 mm, 0.14 mm, 4.2 mm, and 6.6 mm, respectively. Furthermore, 96% patients expressed a preference for receiving anesthesia as brachial plexus block with IV DEX sedation. CONCLUSIONS: Long-duration upper extremity surgery, even longer than 2 h, was feasible under brachial plexus block combined with IV DEX sedation without an anesthesiologist. For patients with low blood pressure and/or low heart rate, it is recommended to adjust the continuous infusion of IV DEX to less than 0.4 µg/kg/h. To ensure that the patients are able to promptly leave the operating room fully awake, IV DEX infusion should be stopped at least 30 min before finishing the operation.

Partial tibial nerve transfer for iatrogenic peroneal nerve palsy after endovenous laser ablation for varicose veins of the lower extremity: A case report.

Postprocedural peroneal nerve palsy after endovenous laser ablation (EVLA) for varicose veins is rare and is associated with poor functional recovery. There have been no reports using tibial nerve transfer for iatrogenic peroneal nerve palsy after EVLA. Herein, we present a case with peroneal nerve injury after EVLA, which was successfully treated by partial tibial nerve transfer for the first time. A 75-year-old female presented with a right foot drop immediately after EVLA of the lesser saphenous vein. The ankle and toe dorsiflexion had a muscle grade of M0 on the British Medical Research Council muscle scale, without voluntary motor unit action potentials (MUAP) in the tibialis anterior (TA) muscle on the needle electromyography. Three months after the injury, surgical nerve exploration revealed a damaged common peroneal nerve with discoloration and scarring at the fibular head. Intraoperative deep peroneal nerve stimulation confirmed the absence of compound muscle action potentials in the TA. The best functioning motor fascicles of the tibial nerve were transferred to the deep peroneal main trunk involving motor branches of the TA, extensor digitorum longus, and extensor hallucis longus (EHL) through the interosseous membrane. The postoperative course was uneventful, with no complications. After 3 months of surgery, nascent MUAP appeared in the TA. After 24 months, the patient regained the TA and EHL muscle function and ambulation without an ankle-foot orthosis and tibial nerve deficits. Thus, our procedure may serve as an alternative to nerve grafting, tendon transfer, and orthoses for better management of the major neural complications associated with EVLA.

Prosthetic Accuracy Depends on the Design of Patient-Specific Instrumentation: Results of a Retrospective Study Using Three-Dimensional Imaging.

To determine accuracy of patient-specific instrumentation (PSI), the preoperative three-dimensional (3D) plan should be superimposed on the postoperative 3D image to compare prosthetic alignment. We aimed to compare prosthetic alignment on a preoperative 3D computed tomography (CT) plan and postoperative 3D-CT image, and evaluate the accuracy of PSI during total knee arthroplasty (TKA). Thirty consecutive knees (30 patients) who underwent TKA using PSI were retrospectively evaluated. The preoperative plan was prepared using 3D CT acquisitions of the hip, knee, and ankle joints. The postoperative 3D CT image obtained 1 week after surgery was superimposed onto the preoperative 3D plan using computer software. Differences in prosthetic alignment between the preoperative and postoperative images were measured using six parameters: coronal, sagittal, and axial alignments of femoral and tibial prostheses. Differences in prosthetic alignment greater than 3 degrees were considered outliers. Two observers performed all measurements. All parameters were repeatedly measured over a 4-week interval. This measurement method's intraobserver and interobserver reliabilities were more than 0.81 (very good). For the femoral and tibial prostheses, absolute differences between the preoperative and postoperative 3D CT images were significantly larger in the sagittal than in the coronal and axial planes (p < 0.001). The outlier rate for the sagittal alignment of femoral and tibial prostheses was significantly higher than that for the alignment of coronal and axial planes (p < 0.001). However, there were no significant differences in the range of motion (ROM) before and after TKA when comparing cases with and without outliers in the sagittal plane. Even though the present study did not reveal any issues with the ROM that depended on the presence of an outlier, accurate verification of prosthetic alignment for individual PSI models may be necessary because the designs, referenced images, and accuracy are different in each model.

Silicone Implant Arthroplasty for Severe Bony Ankylosis of the Proximal Interphalangeal Joints in Rheumatoid Arthritis.

Arthrodesis and prosthetic arthroplasty have been used to treat severe proximal interphalangeal (PIP) joint arthritis. Silicone implant arthroplasty is an established treatment for rheumatoid arthritis (RA) of the fingers. However, few studies have reported the application of silicone implant arthroplasty for the treatment of severe ankylosis of the PIP joint in RA patients. The authors report, for the first time, the case of a 46-year-old woman who presented with severe bony ankylosis of the right fourth and fifth PIP joints at greater than 90° of flexion. Proximal interphalangeal silicone arthroplasty in combination with reconstruction of the extensor mechanism was successfully performed in the affected joints. Four years after surgery, active flexion of the fourth and fifth PIP joints was 55° and 75°, respectively, with an extensor lag of only 5° without pain and joint instability. Proper repair of the extensor mechanism with shortening of the central slips and mobilization of the lateral bands dorsally was most important in maintaining the extended position of the PIP joints. Proximal interphalangeal silicone arthroplasty with intensive reconstruction of the extensor mechanism could become a potential treatment option to maintain joint mobility even in severe ankylosis of the PIP joints in RA patients. [Orthopedics. 2022;45(1):e53-e56.].

Direct Lateral Corpectomy and Reconstruction Using an Expandable Cage Improves Local Kyphosis but Not Global Sagittal Alignment.

Recently, an expandable cage equipped with rectangular footplates has been used for anterior vertebral replacement in osteoporotic vertebral fracture (OVF). However, the postoperative changes in global alignment have not been elucidated. The purpose of this study was to evaluate local and global spinal alignment after anterior and posterior spinal fixation (APSF) using an expandable cage in elderly OVF patients. This retrospective multicenter review assessed 54 consecutive patients who underwent APSF for OVF. Clinical outcomes were compared between postoperative sagittal vertical axis (SVA) > 95 mm and ≤95 mm groups to investigate the impact of malalignment. SVA improved by only 18.7 mm (from 111.8 mm to 93.1 mm). VAS score of back pain at final follow-up was significantly higher in patients with SVA > 95 mm than SVA ≤ 95 mm (42.4 vs. 22.6, p = 0.007). Adjacent vertebral fracture after surgery was significantly more frequent in the SVA > 95 mm (37% vs. 11%, p = 0.038). Multiple logistic regression showed significantly increased OR for developing adjacent vertebral fracture (OR = 4.76, 95% CI 1.10-20.58). APSF using the newly developed cage improves local kyphotic angle but not SVA. The main cause for the spinal malalignment after surgery was postoperative development of adjacent vertebral fractures.

Primary Vascularized Bone Graft for the Extruded Scaphoid Proximal Pole: A Case Report.

CASE: A 52-year-old man sustained a radiocarpal dislocation with extrusion of the scaphoid proximal pole, which was completely detached from the soft tissue. To reduce the risk of avascular necrosis (AVN), treatment involved simultaneous anatomic reduction and internal fixation of the fracture and vascularized bone graft (VBG) for the scaphoid proximal pole. At 4 months, magnetic resonance imaging and 36 months of follow-up radiography showed a healed scaphoid and revealed no evidence of AVN in the scaphoid proximal pole. CONCLUSION: If the risk of AVN is high, we recommend considering the combination of internal fixation and VBG for the fresh scaphoid fracture.

Bone healing of distal radius nonunion treated with bridge plating with bone graft substitutes in combination with systemic romosozumab administration: A case report.

Romosozumab is a humanized, anti-sclerostin monoclonal antibody used to treat osteoporosis, which increases bone formation and decreases bone resorption. It enhances fracture healing and systemic romosozumab administration may have therapeutic potentials for accelerating bone healing of even nonunion. Herein, a 61-year-old heavy smoker male with distal radius nonunion who achieved successful bone union by combination therapy of romosozumab and spanning distraction plate fixation with bone graft substitutes was presented. Through the dorsal approach, atrophic comminuted nonunion of the distal radius was sufficiently debrided. Reduction of the distal radius was performed using indirect ligamentotaxis, and a 14-hole locking plate was fixed from the third metacarpal to the radial shaft. A beta (ß) tricalcium phosphate block was mainly packed into the substantial metaphyseal bone defect with additional bone graft from the resected ulnar head. Postoperatively, systemic administration of monthly romosozumab was continued for six months. Complete bone union was achieved 20 weeks postoperatively and the plate was, then, removed. Wrist extension and flexion improved to 75o and 55o, respectively, without pain, and grip strength increased 52 weeks postoperatively from 5.5 kg to 22.4 kg. During romosozumab treatment, bone formation marker levels increased rapidly and finally returned to baseline, and bone resorption marker levels remained low. In conclusion, combination of systemic romosozumab administration and grafting ß-tricalcium phosphate with bridge plating provides an effective treatment option for difficult cases of comminuted distal radius nonunion with risk factors such as smoking, diabetes, and fragility.

Evaluation of the accuracy of resected bone thickness based on patient-specific instrumentation during total knee arthroplasty.

BACKGROUND: In total knee arthroplasty (TKA) using patient-specific instrumentation (PSI), the correlation between the preoperative surgical plan and intraoperative resection size is unclear. The aims of this study were to evaluate whether the computed tomography (CT)-based PSI surgical plan can be executed accurately and to determine the accuracy of bone resection in TKA using PSI. METHODS: Data of 45 consecutive knees undergoing TKA using CT-based PSI were retrospectively evaluated. The preoperative plan was prepared using three-dimensional CT acquisitions of the hip, knee, and ankle joints. Resected bone thicknesses of the femoral condyle of the distal medial, distal lateral, posterior medial, posterior lateral, and medial and lateral tibial plateaus were measured with a Vernier caliper intraoperatively. Then these respective measurements were compared with those in the preoperative CT-predicted bone resection surgical plan, and the measured thickness of resection was subtracted from the planned resection thickness. Errors were defined as: acceptable, ≤ 1.5 mm; borderline, 1.5-2.5 mm; and outliers, > 2.5 mm. RESULTS: Overall, 22 (48.9%) knees had no outliers. There were 20 (44.4%) and 3 (6.7%) knees in which only 1 and 2 resection planes were outliers, respectively. The posterior medial tibial plateau had the lowest proportion of acceptable cuts (44.4%). Posterior femoral resection including the medial and lateral condyles had more outliers (n = 18/90 cuts, 20.0%) (p < 0.001) than the tibial condyles (n = 3/90 cuts, 3.3%) and distal femoral cuts (n = 6/90 cuts, 6.7%). The posterior surface of the femur, where the incidence of outliers was higher, tended to have a higher proportion of undercuts than other surfaces of the femur (> 80%). CONCLUSIONS: PSI showed only fair-to-moderate accuracy. The cutting guide for the posterior femur was less accurate than that for the tibia and distal femur. Specific attention is required when cutting the posterior femur. The PSI design needs to be improved to reduce errors.

Differences in surgical outcome after anterior corpectomy and reconstruction with an expandable cage with rectangular footplates between thoracolumbar and lumbar osteoporotic vertebral fracture.

BACKGROUND: Anterior and posterior spinal fixation (APSF) can provide rigid structural anterior column support in patients with osteoporotic vertebral fracture (OVF). A new rectangular footplate designed based on biomechanical studies of endplates provides better resistance to subsidence. However, differences in characteristics exist between the thoracolumbar and lower lumbar spine. The purpose of this study was to evaluate the surgical outcomes following APSF using an expandable cage with rectangular footplates in the thoracolumbar/lumbar region. METHODS: Consecutive patients who underwent APSF for OVF at multiple centers were retrospectively reviewed. Clinical and radiographic evaluations were performed by dividing the patients into thoracolumbar (TL, T10-L2) and lumbar (L, L3-L5) groups. Surgical indications were incomplete neurologic deficit or intractable back pain with segmental spinal instability. Surgical outcomes including the Japanese Orthopaedic Association (JOA) score and reoperation rate were compared between TL and L groups. RESULTS: Sixty-nine patients were followed-up for more than 12 months and analyzed. Operative intervention was required for 35 patients in the TL group and 34 patients in the L group. Mean ages in the TL and L groups were 76.5 years and 75.1 years, respectively. Intra-vertebral instability was more frequent in the TL group (p<0.001). Screw fixation range was significantly longer in the TL group (p=0.012). The rate of cage subsidence did not differ significantly between the TL group (46%) and L group (44%). Reoperation rate tended to be higher in the TL group (p=0.095). Improvement ratio of JOA score was significantly better in the L group (60%) than in the TL group (46.9%, p=0.029). CONCLUSION: APSF using an expandable cage was effective to treat OVF at both lumbar and thoracolumbar levels. However, the improvement ratio of the JOA score was better in the L group than in the TL group.

Posttraumatic triggering of the extensor pollicis brevis tendon in de Quervain's disease successfully diagnosed with ultrasonography: A case report.

Triggering due to de Quervain's disease is exceedingly rare. This is the first successfully diagnosed case of the snapping phenomenon of the extensor pollicis brevis (EPB) tendon in de Quervain's disease evaluated with preoperative dynamic ultrasonography, clearly demonstrated in an intraoperative video, and treated with decompression of EPB subcompartment only under a wide-awake surgery. Dynamic ultrasonographic images identified snapping caused by unsmooth excursion of an enlarged EPB tendon in a separate subcompartment. In snapping de Quervain's disease, ultrasonographic evaluations and wide-awake surgery are essential to exactly diagnose and successfully treat the snapping condition of the EPB and/or APL tendons.

Simultaneous Opposition Tendon Transfer with Median Nerve Decompression for Severe Bilateral Carpal Tunnel Syndrome in Adolescents with Hunter Syndrome: A Case Report.

Although carpal tunnel syndrome (CTS) is exceedingly rare in children, its prevalence in those with Hunter syndrome, mucopolysaccharidosis type II, is high. With the advent of hematopoietic stem cell transplantation and enzyme replacement therapy, the survival of patients with Hunter syndrome has dramatically improved. With improved longevity in these patients, CTS continues to progress with age. However, most patients with Hunter syndrome with CTS have generally been treated with an open carpal tunnel release (OCTR) only, without considering the severity. Here, we present a mid-term follow-up of a 16-year-old patient with Hunter syndrome associated with severe bilateral CTS successfully treated by the simultaneous opposition tendon transfer with an OCTR to improve the thumb function. Intraoperatively, the median nerve was constricted and flattened with congestion by the transverse carpal ligament. External and internal neurolysis of the scarred median nerve were performed and found epineural fibrosis and tethered epineurium. An intraneural lipoma of the left median nerve was especially resected with epineurotomy. During neurolysis and tendon transfer, the soft tissue was very viscous, a characteristic of mucopolysaccharidoses. Transferring the tension of the palmaris longus tendon to the abductor pollicis brevis for the thumb palmar abduction should be stronger than routine adult patients because the soft tissue such as the tendon excursion is stickier and more contracted in patients with Hunter syndrome. Postoperatively, a thumb spica splint was applied for 3 weeks, and then active motion exercises were cautiously started to prevent joint contracture. Early recognition and surgical intervention for CTS are essential in patients with Hunter syndrome.

Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports.

BACKGROUND: While some traumatic closed index extensor tendon ruptures at the musclotendinous junction have been previously reported, closed index extensor tendon pseudorupture due to intertendinous attenuation is exceedingly rare with only one case report of a gymnastics-related sports injury in the English literature. Herein, we report two non-sports injury related cases of traumatic index extensor tendon attenuation mimicking closed tendon rupture, including the pathological findings and intraoperative video of the attenuated extensor indicis proprius tendon. CASE PRESENTATION: A 28-year-old man and a 30-year-old man caught their hands in a high-speed drill and lathe, respectively, which caused a sudden forced flexion of their wrists. They could not actively extend the metacarpophalangeal joints of their index fingers. Intraoperatively, although the extensor indicis proprius and index extensor digitorum communes tendons were in continuity without ruptures, both tendons were attenuated and stretched. The attenuated index extensor tendons were reconstructed either with shortening by plication or step-cut when the tendon damage was less severe or, in severely attenuated tendons, with tendon grafting (ipsilateral palmaris longus) or tendon transfer. Six months after the operation, the active extension of the index metacarpophalangeal joints had recovered well. CONCLUSIONS: Two cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. We recommend WALANT (wide-awake local anesthesia and no tourniquet) in the reconstruction surgery of index extensor tendon attenuation to determine the appropriate amount of tendon shortening or optimal tension for tendon grafting or transfer. Intraoperative voluntary finger movement is essential, as it is otherwise difficult to judge the stretch length of intratendinous elongation and extent of traumatic intramuscular damage affecting tendon excursion.

A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap.

Adhesion neuropathy of the median nerve with persistent pain can be a challenging problem. Currently, coverage of the median nerve with a well-vascularized soft tissue is deemed necessary after secondary neurolysis. Herein, we reviewed the outcomes of seven patients with a persistent median nerve neuropathy after a primary open carpal tunnel release or a median nerve repair, treated with neurolysis and median nerve wrapping with radial artery perforator adipose flaps. During the revision surgery, after a careful and complete neurolysis of the scarred median nerve, the distally based radial artery perforator adipose flap without its fascia was raised and rotated to wrap the median nerve. The mean size of the perforator flap was 1146 mm2, which was enough to wrap the median nerve in all patients. At 26 months postsurgery, both the visual analog scale score for pain with tingling, and the patient-reported outcome measures improved. There was no recurrence of the median nerve adhesion neuropathy and no major complications were noted. Tinel's sign at the palmar wrist completely disappeared in four patients and was relieved in three patients. The median distal motor latency becomes recordable, and closer to a normal compound motor action potential postoperatively in all patients. Secondary neurolysis and median nerve wrapping with a radial artery perforator adipose flap, which was modified to be softer and thinner than the radial artery perforator adipofascial flap, was a successful treatment for the recurrent median nerve neuropathy in terms of both pain relief and restoration of the hand function.

Iatrogenic displacement of the metacarpal head of the index finger while attempting closed reduction of a complex dorsal metacarpophalangeal joint dislocation.

We describe the case of an 84-year-old woman with a dorsal dislocation of the metacarpophalangeal (MCP) joint of the left index finger. Closed reduction was performed at an orthopaedic clinic which led to an iatrogenic complete displacement of the second metacarpal head to the volar side. Because reduction was impossible, surgery was performed. The metacarpal head was reduced and fixed with two headless intramedullary screws. Careless attempting a closed reduction of the complex dorsal MCP joint dislocation might be contraindicated in elderly patients with bone fragility.

Autogenic Rib Graft for Atlantoaxial and Occipitocervical Fixation in Pediatric Patients.

Study Design: Retrospective case series. Purpose: To evaluate surgical outcomes and effectiveness of an autogenic rib graft for upper cervical fixation in pediatric patients. Overview of Literature: Autogenic bone grafts have long been considered the 'gold standard' bone source for posterior cervical fusion in pediatric patients. However, there are some unsolved problems associated with donor-site morbidity and amount of bone grafting. Methods: We studied five consecutive pediatric patients who underwent atlantoaxial fixation or occipitocervical fixation (OCF) using an autogenic rib graft with at least 2 years of follow-up (mean age, 9.8 years; mean follow-up period, 73.0 months). Two patients underwent OCF without screw-rod constructs and three patients with screw-rod constructs. Autogenic rib grafts were used in all patients. We evaluated the surgical outcomes including radiographic parameter, bony union, and perioperative complications. Results: The atlantoaxial interval (ADI) was corrected from 11.6 to 6.0 mm, and the C1-2 angle was corrected -14.8° to 7.8°. The C2-7 angle was reduced from 31° to 9° spontaneously. Two patients with OCF required revision surgery due to loss of correction. Patients did not experience any complication associated with the donor sites (rib bone grafts). Six months postoperation X-rays clearly showed regeneration of the rib at the donor sites. Bony fusion was achieved in all patients; however, bony fusion occurred more slowly in patients without screw-rod constructs compared with patients with screw-rod constructs. Bone regeneration of the rib was observed in all patients with no complications at the donor site. Conclusions: Autogenic rib grafts have advantages of potential bone regeneration, high fusion rate, and low donor-site morbidity. In addition, a screw-rod construct provides better bony fusion in pediatric patients with OCF and atlantoaxial fixation.

A Case of Osteomyelitis after Calcaneal Fracture Treated by Antibiotic-Containing Calcium Phosphate Cements.

Calcaneal osteomyelitis (CO) is considered to be difficult to cure when it turned into a chronic phase. We report one case of calcaneal osteomyelitis which arises after the operation of calcaneal fracture. Remission was obtained by performing curettage of the infected cancellous bone of the calcaneal body and filling antibiotic-containing calcium phosphate cements (CPC) within its bone defect. This one-stage surgery is useful to treat calcaneal osteomyelitis.

Irreducible Volar Rotatory Subluxation of the Proximal Interphalangeal Joint of the Finger.

We describe 4 cases of irreducible volar rotatory subluxation of the proximal interphalangeal (PIP) joint of the finger that required open reduction. All of the patients had radiographically proven (in lateral-view radiographs) volar rotatory subluxation of the PIP joint, without fracture. The causes of irreducibility were interposition of the lateral band about the condyle of the middle phalanx in 2 cases, interposition of the collateral ligament in 1 case, and scarring of the injured central slip in 1 case. Rupture of the collateral ligament of one side was found in all cases. Acceptable results were provided with all cases after restoration of the collateral ligaments and the damaged parts. Accurate early diagnosis by careful physical examination and obtaining true lateral radiographs of the PIP joint is important.